<div dir="ltr"><p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">BOSTON (New York Times, May 5, 2014)— The death rate in Massachusetts dropped
significantly after it adopted mandatory health care coverage in 2006, a study
released Monday found, offering evidence that the country’s first experiment
with universal coverage — and the model for crucial parts of President Obama’s
health care law — has saved lives, health economists say.</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">The study tallied deaths in Massachusetts from 2001 to 2010
and found that the mortality rate — the number of deaths per 100,000 people —
fell by about 3 percent in the four years after the law went into effect. The
decline was steepest in counties with the highest proportions of poor and
previously uninsured people. In contrast, the mortality rate in a control group
of counties similar to Massachusetts in other states was largely unchanged.</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">A national 3 percent decline in mortality among adults under
65 would mean about 17,000 fewer deaths a year.</span></p>
<p class="MsoNormal" style="margin-left:0.5in"><span style="font-size:12pt;font-family:'Times New Roman',serif"> </span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">“It’s big,” said Samuel Preston, a demographer at the
University of Pennsylvania and an authority on life expectancy. Professor
Preston, who was not involved in the study, called the study “careful and
thoughtful,” and said it added to a growing body of evidence that people with
health insurance could reap the ultimate benefit — longer life.</span></p>
<p class="MsoNormal"><br></p>
<p class="MsoNormal"><b><span style="font-size:18pt;font-family:'Times New Roman',serif">A Drop in Mortality </span></b></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">The death rate in Massachusetts declined after the state’s
health care law was adopted in 2006, while the rate in similar counties in
other states stayed flat. </span></p>
<p class="MsoNormal"><span style="font-family:'Times New Roman',serif;font-size:12pt"><br></span></p><p class="MsoNormal"><span style="font-family:'Times New Roman',serif;font-size:12pt">Experts said the study, which was published online Monday in
the </span><a href="http://annals.org/article.aspx?articleid=1867050" style="font-family:'Times New Roman',serif;font-size:12pt"><span style="color:blue">Annals of Internal Medicine</span></a><span style="font-family:'Times New Roman',serif;font-size:12pt">, will not settle the
long-debated question of whether being insured prolongs life, but it provides
the most credible evidence yet that it might. Still, health improvements can
take years to surface in mortality data, and some researchers were skeptical of
the magnitude and suddenness of the decline.</span><br></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif"><br></span></p><p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">“Health care is a much more involved process — you don’t
just sign up and suddenly get well,” said Joseph Antos, a health economist at
the conservative American Enterprise Institute.</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">Massachusetts is whiter and more affluent than most states,
and has more doctors per capita and fewer uninsured people. But researchers
said that the state’s health insurance law nevertheless amounted to the best
natural experiment the country has had for testing the effects of a major
insurance expansion on a large population.</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif"><br></span></p><p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">Another study, in Oregon, found that Medicaid, the insurance
program for the poor, improved mental health and financial security, but not
physical health, and the study was too small to gauge mortality effects.</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif"><br></span></p><p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">“This is an important piece of the puzzle,” Katherine
Baicker, a professor of health economics at the Harvard School of Public
Health, who took part in both studies, said of the Massachusetts one. “Putting
the evidence together paints a very strong picture that expanding insurance
substantially improves the well-being of people who get it.”</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif"><br></span></p><p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">In the waiting rooms of the East Boston Neighborhood Health
Center, bustling with a working-class clientele, doctors said much had changed
since the state insurance law passed in 2006. People are less likely to put off
care out of fear of unaffordable bills, and patients with diabetes can get
medication regularly.</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif"><br></span></p><p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">Dr. Stelios Maheras, medical director of the emergency
department, said some patients used to ask for prices “like at the
supermarket.” He recalled one patient who was having chest pains but refused an
ambulance because he was afraid of the bill.</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">“I said, ‘You can’t drive yourself to the hospital — that’s
a stress test all on its own!’” Dr. Maheras said. “The attitude has totally
changed,” he said, adding that his patients now felt less financially
vulnerable and more confident.</span></p>
<p class="MsoNormal" align="center" style="text-align:center"><span style="font-size:2.5pt;font-family:Arial,sans-serif;color:rgb(191,190,189)">Advertisement</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">In Suffolk County, which includes Boston, the death rate for
adults under 65 dropped by about 7 percent from 2005 to 2010, the study’s
authors said.</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif"><br></span></p><p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">There have been patchy efforts to improve coverage for the
poor in states like Arizona, Maine and New York, but Massachusetts is the only
state to fully overhaul its health system to cover almost everybody.</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif"><br></span></p><p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">But studying the state in isolation was problematic: Was the
mortality decline due to expanded insurance coverage, or other factors such as
improved eating habits or lower smoking rates? The authors identified 513
counties in 46 other states that were most similar to Massachusetts before
reform in demographics and levels of poverty and insurance, then compared their
mortality rates with that of Massachusetts. They found that the rate declined
2.9 percent in Massachusetts, but remained flat in counties outside the state.</span></p><p class="MsoNormal"><span style="font-family:'Times New Roman',serif;font-size:12pt"><br></span></p><p class="MsoNormal"><span style="font-family:'Times New Roman',serif;font-size:12pt">Dr. Catherine Silva, of the
East Boston center, said previously uninsured patients were now less likely to
disrupt treatment. Credit Dominic Chavez for The New York Times</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">Researchers also examined death rates for people 65 and
over, a population that had been minimally affected by the insurance overhaul.
Mortality patterns over time in that age group were the same in Massachusetts
and in the control counties.</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif"><br></span></p><p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">Dr. Benjamin Sommers, the lead author and a health economist
and physician at the Harvard School of Public Health, cautioned that
researchers did not have individual data on the 270,000 people who had gained
insurance in the state, and could not tell for sure whether it was the
expansion that had driven the mortality decline.</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif"><br></span></p><p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">Dr. Sommers said that he spent several hours a week advising
the Department of Health and Human Services, which pays Harvard for his time,
but that it had neither funded nor vetted the study.</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">Experts said the study was the best attempt yet to isolate
the effects of insurance.</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif"><br></span></p><p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">David O. Meltzer, a health economist from the University of
Chicago, who was not involved in the study, said one of the study’s strengths
was its size. It looked at four million people in Massachusetts — the entire
population age 20 to 64 — and compared them with more than 44 million people in
control counties.</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif"><br></span></p><p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">“In the hierarchy of evidence, this ranks way above
everything we’ve seen in the past in terms of the effects on mortality,”
Professor Meltzer said.</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif"><br></span></p><p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">The biggest declines happened for conditions that are more
likely to be deadly if not caught early — for example, infections from
complications of diabetes, heart attacks and cancer.</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif"><br></span></p><p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">Dr. Catherine Silva, a primary care physician at the East
Boston health center, said some fatalities might have been prevented by helping
people control their high blood pressure and cholesterol, which can increase
the risk of heart attacks. She recalled a patient who had hypertension, but
dropped out of treatment when she lost insurance, and came back three years
later with breast cancer that proved tricky to treat because she had
uncontrolled high blood pressure and diabetes.</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif"><br></span></p><p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">“That conversation about why did you leave me for three
years, that doesn’t happen anymore,” she said.</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif"><br></span></p><p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">Researchers have long debated whether having health
insurance and better access to medical care saves lives, but it has been hard
to construct a study to settle the issue. In 2002, the Institute of Medicine
estimated that a lack of health insurance was responsible for 18,000 deaths a
year in the United States. But in 2009, a researcher from the University of
California found that the survival rate of uninsured people resembled that of
insured people.</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif"><br></span></p><p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">There will be more evidence, as well, in coming years. The
Affordable Care Act is its own sweeping experiment, as only about half the
states expanded Medicaid.</span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif"><br></span></p><p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">“It’s very unfortunate for people living in states not
expanding Medicaid,” said Richard Kronick, a health policy official at the
Department of Health and Human Services, “but from the point of view of
research, it’s a gold mine.”</span></p>
<p class="MsoNormal"><b><span style="font-size:12pt;font-family:'Times New Roman',serif"><br></span></b></p><p class="MsoNormal"><b><span style="font-size:12pt;font-family:'Times New Roman',serif">Correction: May 5, 2014 </span></b><span style="font-size:12pt;font-family:'Times New Roman',serif"></span></p>
<p class="MsoNormal"><span style="font-size:12pt;font-family:'Times New Roman',serif">An earlier version of this article misstated where the
decline in the death rate was steepest. It was in counties with the highest
proportions of poor and previously uninsured people, not poor and uninsured
people.</span></p>
<p class="MsoNormal"> </p></div>